Provider Demographics
NPI:1942211057
Name:UDING, KELLY N (PT)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:N
Last Name:UDING
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:N
Other - Last Name:LAIBEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1620 HIGHWAY Z
Mailing Address - Street 2:
Mailing Address - City:PEVELY
Mailing Address - State:MO
Mailing Address - Zip Code:63070-1511
Mailing Address - Country:US
Mailing Address - Phone:636-224-7511
Mailing Address - Fax:636-224-7512
Practice Address - Street 1:1620 HIGHWAY Z
Practice Address - Street 2:
Practice Address - City:PEVELY
Practice Address - State:MO
Practice Address - Zip Code:63070-1511
Practice Address - Country:US
Practice Address - Phone:636-224-7511
Practice Address - Fax:636-224-7512
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001032800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO142430057Medicare PIN